Original Article

Bull Emerg Trauma 2013;1(1):34-37.

Predictive Value of Biochemical Markers for Extremity Vascular Trauma Outcome Shahram Bolandparvaz, Behzad Ghaffari*, Seyed Mohsen Mousavi, Shahram Paydar, Hamid Reza Abbasi Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Corresponding author: Behzad Ghaffari

Address: Trauma Research Center, Shahid Rajaei Hospital, Chamran Avenue, Shiraz, Iran Tel: +98-912-7387102 Fax: +98-711-6254206 e-mail: [email protected]

Received: August 16, 2012 Revised: October 13, 2012 Accepted: December 2, 2012

Objective: To evaluate the predictive value of some biochemical markers in the outcome of extremity vascular trauma. Methods: This study comprised 30 patients with traumatic arterial injury and acute limb ischemia referred to Namazi hospital affiliated with Shiraz University of Medical Ssciences, over a period of 8 months, from Sep 2009 to Jul 2010. Venous blood samples were drawn from distal ischemic limb to determine pH, HCO3-, PCO2, PO2, Na+, and K+ before definitive surgical intervention. Comparable samples were also obtained from veins of nonischemic upper extremities. The biochemical assays were compared after monitoring the revasculurized limbs and evaluation of viability during a period of 7 days. Results: The mean age of the patients was 28.3 ± 7.8 (range: 18–56) years. Two (6.6%) patients underwent amputation because of developing irreversible limb ischemia after vascular reconstruction. Both patients had blunt traumatic knee injury accompanied by nerve, vein and soft tissue damage. The statistical analysis showed correlations between parameters, except for Na+, of local (ischemic limb) and systemic samples. In this context, the highest correlation was observed in regard to HCO3-. Conclusion: The correlation was most pronounced with respect to HCO3-. Ischemic limbs exhibited reduction in pH and PO2 but, PCO2 and K increased after ischemia of injured limbs. PO2 reflects tissue perfusion and is of value in predicting the outcome. We believe that blunt trauma and associated nerve, vein and soft tissue injuries pose negative prognostic effects on limb survival postoperatively. Keywords: Trauma; Limb ischemia; Vascular injury; Vascular reconstruction; Biochemical assay

Please cite this paper as:

Bolandparvaz S, Ghaffari B, Mousavi SM, Paydar S, Abbasi HR. Predictive Value of Biochemical Markers for Extremity Vascular Trauma Outcome. Bull Emerg Trauma. 2013; 1(1):34-37.

Introduction

O

ver the past five decades of experience in the management of extremity vascular trauma, a number of factors have been identified which directly influence patients’ outcome. These include the time interval between injury and treatment, mechanism of injury, anatomic location, associated injuries, age, comorbidities and clinical presentation [1]. Knowledge of these prognostic factors is essential for the appropriate evaluation and treatment of afflicted patients. The time interval from injury to treatment 34

is perhaps the most critical determinant of salvage of both life and limb, following extremity vascular injury, as it is for all forms of trauma. This is explained by the time-dependent nature of the two major consequences of vascular injury, hemorrhage and ischemia [2]. Strong correlation between delay in treatment of arterial injuries and limb loss was shown in multiple studies such as, World War II, Afghanistan War, etc. Several civilian clinical series have confirmed close correlation of limb loss with delay in revascularization, especially when extremity arterial injury is complicated by associated injuries to vein, soft tissue,

Journal compilation © 2013 Trauma Research Center, Shiraz University of Medical Sciences Bull Emerg Trauma 2013;1(1)

Bolandparvaz Sh et al.

and bone [1]. Even salvaged limbs are subject to functional disability, following treatment delay, due to nerve and muscle damage, as well as the development of potentially dangerous vascular complications such as pseudoaneurysms and arteriovenous fistulas (AVFs) [3]. Many studies have established the critical time interval, for restoration of limb perfusion and optimal limb salvage, to be at most 6-8 hours following extremity vascular trauma [4]. The degree of ischemia and extent of collateral circulation affect tissue tolerance of delay. Therefore, prompt diagnosis and treatment of vascular injuries must be a major goal of management of all extremity traumas [4]. Mechanisms of blunt injury involve a wider application of force, with greater damage to extremity vessels and surrounding structures than is imparted by penetrating trauma. Blunt vascular injuries are associated with a more difficult diagnosis and higher rates of amputation and severe dysfunction than simple penetrating vascular injuries which are typically clean, isolated, and more easily diagnosed and repaired [1]. Among Penetrating injuries, stabs impart the least destructive force and are associated with a small and discrete area of injury. High-velocity gunshot and shotgun wounds create a level of damage similar to blunt trauma, in terms of the complexity and extent of the damage, the difficulty of diagnosis and treatment, and the higher rates of limb loss. If the interval between trauma and vascular reconstruction is prolonged beyond 4-6h, the possibility of surgical success is gradually reduced with increasing risk of kidney damage or even death. In these situations physical examination by surgeon is mainstay of decision making. Vascular reconstruction has to be performed when ischemic limb seems viable by examination and post-traumatic interval of less than 4-6 hours. On the other hand, when the limb is necrotic the decision making becomes very difficult [5,6]. But between these two states, taking decision to restore blood to the injured limb is controversial especially when the surgeon lacks extensive experience. Therefore, we should weigh the risk of reperfusion syndrome against the possibility of saving the borderline viable limb. In limb injuries involving amputation, laceration injuries, or compartment syndrome a circulatory insufficiency with a total or subtotal ischemia may occur and jeopardize the result of reconstructive surgery. Transcutaneous oxygen monitoring has been shown to reflect tissue perfusion and has been recommended for predicting the final outcome of major vascular trauma of the limb. The effect of transient iatrogenic ischemia, caused by tourniquet pressure, on local and systemic blood gas analysis has been demonstrated in animals [7]. But similar studies have not yet been reported in humans. The http://www.beat-journal.com

present study was thus performed to determine whether biochemical assay can predict the outcome of traumatic acute ischemic limb after vascular reconstruction.

Materials and Methods The case records of 30 patients with acute arterial injuries included both blunt and penetrating (gunshot, shotgun, stab and iatrogenic) injuries. These patients presented with acute traumatic limb ischemia 4 to 6 hours after trauma, and viable ischemic limb based on Rutherford criteria. The study did not include patients undergoing primary amputation due to non-salvageable injuries, and those having injuries of ulnar or radial arteries. Other excluded cases were those without main arterial injuries such as branch damage as well as patients with injury to hands, feet and legs. All traumatized patients were initially resuscitated by emergency trauma team. Bleeding was transiently controlled by packing or tourniquet pressure. Those with vascular injuries were evaluated by vascular and orthopedic surgeons to salvage the involved limb and the extent of damage to bone, soft tissue and nerve. The diagnosis of a vascular injury was mainly based on clinical findings. Only a few duplex ultrasound examinations were done, without performing any arteriographic studies. Venous sampling was taken from distal ischemic limb for determining pH, HCO3, PCO2, PO2, Na+, and K+ before definitive surgical intervention. Comparable venous samples also were taken from non-ischemic upper extremities. Standard incisions were made to expose the arteries. Methods used to repair the injured arterial segments included lateral arteriorrhaphy, resection and endto-end anastomosis, autogenous vein graft, and synthetic graft interpositions. If possible, veins were repaired by lateral venorrhaphy or resection and end-to-end anastomosis, but graft interposition was not used. Fracture fixation preceded arterial repair in all cases. However, temporary shunts were applied to decrease warm ischemia time in patients with critically ischemic limbs. Nerve injuries were repaired aptly and soft tissue cover was performed. Systemic heparinization was used during repair of isolated vascular injuries. Fasciotomies were used liberally especially with delayed presentation, extremity swelling and/or combined arteriovenous injuries. Associated organ injuries were managed as indicated by relevant surgical teams. Antibiotics, mainly Cefazoline, were administered, depending on the extent of associated injuries. Revasculurized limbs and viability were monitored and evaluated for 7 days. All statistical analyses were performed with the 35

Extremity Vascular Trauma Outcome Prediction

Statistical Package for Social Sciences version 15.0 (SPSS Inc., Chicago, IL, USA). Utilizing student’s t-test was used to compare between parametric data sets. A p-value less than 0.05 was considered statistically significant. Results Over 8 months starting from Sep 2009 to Jul 2010, a total of 32 patients with traumatic arterial injuries and acute limb ischemia admitted to Nemazee hospital, participated in this project, excluding primary amputations and all patients with irreversible limb ischemia. Two patients died before 7 postoperative days, and excluded from the study, but their injured limb was preserved after arterial reconstruction. Right-sided pneumonectomy was conducted on one of them, because of concurrent right lung injury. Another one had received massive transfusion and developed multi- organ dysfunction. Of 30 patients under study, 28 were males and two females aged from18-56 years and the mean age of 28.6 ± 8.2 years. Types of injuries were gunshot (6 cases, 20%), stab wound (17 cases, 56.6%), glass injury (1 case, 3.3%), blunt trauma (4 cases,13.3%) and iatrogenic (2 cases, 6.7%). Axillary artery was the most common injured artery (4 cases, 13.3%) followed by Brachial artery (8 cases, 26.6%), ulnar and Radial artery (4 cases, 13.3%), femoral artery (1 case, 3.3%), superficial femoral artery (4 cases, 13.3%) and popliteal artery (9 cases, 30%). Mean operative time was 160 (110–250) minutes. Vascular reconstruction was performed by synthetic graft interposition for two patients, reverse saphenous graft interposition performed in 11 cases, arterial repair in 10 patients and end to end anastomosis in 7 cases. Four quadrants Fasciotomy was done in 9 patients with lower extremity injury. Also one patient underwent hematoma evacuation, and bone reapposition was performed in 4 cases. Two patients were re-operated due to bleeding from sites of vascular repair and were successfully controlled.The limbsalvage rate was 93.3% (28/30). Of 5 patients (16.6%) having associated orthopedic fixation, 1 (20%) was before and 4 (80%) after revascularization. Rhabdomyolysis did not occur postoperatively but hemodialysis was performed in one case. After vascular reconstruction two patients developed irreversible limb ischemia and underwent

amputation. They had blunt traumatic knee injury with accompanied nerve, vein and soft tissue damage. One of them had history of previous tibial fracture for which open reduction and internal fixation had been done. However, upper extremity vascular reconstructions were totally successful. As summarized in Table 1, the levels of pH (p

Predictive Value of Biochemical Markers for Extremity Vascular Trauma Outcome.

To evaluate the predictive value of some biochemical markers in the outcome of extremity vascular trauma...
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